Thursday, July 23, 2015

Opt in; Opt out

Before I proceed with this blog, let me lay down a few cards, especially regarding what gives me at least some mileage to pass an opinion. 

I am a Consultant in Diabetes who has so far:
Been a Consultant in an acute Trust contributing to diabetes and general medicine
Been a Consultant working within 2 community Trusts 
Been a clinical manager for an acute Trust as well as a community Trust
Work on a CCG Board
Work/involved with think tank such as the Kings Fund
Worked with quangoes eg:NHS Institute of Innovation& Improvement- renamed as NHSIQ later

Happy with that? Ok goes.

It's time now for this 7/7 debate to have some pure facts...facts based on experience of working within different formats/organisations, facts away from the raw emotions understandably generated recently. So let's get to the nub.

Consultant opt outs part 1:  Let's be crystal clear on this..emergency work has no opt outs. The NHS needs 7/7 emergency cover and that's something any manager worth his or her salt, with backing from clinical leaders, should and must deliver. There is NO contract obstruction to that. the question thus is...of people are struggling to implement what is already IN the contract, what good will a contract change actually achieve? Get better skilled managers, clinical or otherwise, not contract changes.

Opt outs part 2: There indeed are opt outs in Consultant contracts. They are for elective work. So let's see why many want to have this removed. 

The one for all principle: if no one else has it, why should Consultants? A fair point. No one is special indeed...but let's look at those who have no opt outs. Specialist Nurses, many elective clinics are run by them? Very few..some due to lack of resource, some due to lack of need, some due to lack of will. So..if we can't even implement elective work for those who have the opt in..what good would a contract change do without the investment? 

Financial: weekend elective work is indeed done- at a cost. Consultants and others involved are thus paid higher rates, as negotiated locally. This costs more and thus is an issue. But it's an issue because the Trusts are running out of money and need more elective work, thereby money..while they get beaten over a rack when the targets get missed. Why are targets getting missed? Because the surgical beds are filled with medical patients who can't go home due to lack of funding in social services etc. Cue last minute surgical lists cancelled, cue targets being missed, cue waiting list initiatives. How vicious do you want a cycle to be?

Political: negotiation tactics always involves decrying the other side( especially when it's tough) and painting Consultants as the pantomime villains plays to the classic view of decrying the higher paid individual. I have no issues with that but that's slightly underestimating the faith and belief other colleagues within the NHS have towards Consultants too. Anyway, it's politics to try and force the other side to the table..weakened by public pressure...the problem is you need the Consultant to deliver the force or contract battles, you can achieve only so much. An engaged Consultant or for that matter anyone will deliver far more productivity..and accusing medics of not doing something they have been doing for years, has somehow brought many warring factions together.
I am also aware that there are patients who fall between emergency and elective. That indeed is the case..and that is about access, about using resources differently..and no, you don't need contract changes for that. Example? Let's say neurology. Does everywhere have a 7/7 service? the responsibility for that falls on the physician on call. Sometimes it care beyond their expertise..but rather than input resources into 1 specific specialty, that's where networks come into play...for that you need organisations to think beyond their silos, think beyond their own bottom lines...that's got little to do with contracts.

Finally, to the BMA...apart from the message from last week ( I repeat, do NOT put the next generation on the line and protect the present) here's something to mull over.."You will not get what you deserve, you will get what you negotiate". Is there money already in the overall contract? Is there a place to consider the Clinical Excellence awards and making them ALL time bound? is there a place to reconsider automatic increments? Is there money there to help fund elective work where it is needed and make the savings needed which is otherwise being burnt via WLIs?

As Consultants, we have always taken pride in leading change in our services and for once, it is good to show unity. Here lies a perfect opportunity once the angst has died down and the point is make some suggestions and overtures....if not to do something which many have  struggled so turn this debate into one simple issue of "Show me the money, we are here to do what is needed". Politicians come with a mandate and are sometimes also let down by advisors, advisors who have left the coal face long ago, high on the ambition and intention scale, low on keeping pace with developments at the grassroots  Don't also forget this will also compete with safe nursing staffing as well as primary care investment. 

Finally? If indeed there is no or limited money...then we talk about prioritisation. If safe staffing on wards is indeed of the highest priority, then maybe elective work on weekends isn't. In which case, the debate about "opt outs" is just a fallacy, nothing more..and nothing less. Or shiver me timbers..are we talking about electives on weekends which a public taxation can't afford at present funding...are we now heading towards asking the public to pay for an upgraded service? 

We shall indeed see. Now THAT would be a whole different debate regards opt in and opt out.

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